CYTOPATHOLOGY

Randanan Bandaso
Bagian Patologi Anatomi FK Unhas.

DEFINITION
Cytopathology refers to diagnostic techniques
that are use to examine cells from various
body sites to determine the cause or nature
of disease

HISTORY 1
IN THE MID -19 CENTURY

INVESTIGATOR DETECTED ABNORMAL

CELLS IN BODY FLUIDS, SUCH US
URINE,SPUTUM,EFFUSION AND GASTRIC
SECRETION
1928 GEORGE PAPANICOLAOUIN THE
NEW YORK CITY PRESENTED PAPER:
NEW CANCER DIAGNOSTIC
IN THE SAME YEAR AURELI BABES OF
BUCHAREST INDEPENDENTLY
REPORTED SIMILAR FINDING.

HISTORY 2

PAPS TEST INITIALLY RECEIPT

SKEPTICISM.
NOWADAYS PAPS TEST HAS BEEN
WIDELY ACCEPTED AS THE MOST
RELIABLE SCREENING TEST

CYTOLOGICAL METHODS

EXFLOATIVE CYTOLOGY
ABRASIVE CYTOLOGY
FINE NEEDLE ASPIRATION CYTOLOGY

TO OBTAIN OPTIMAL RESULT

In aspirating solid masses one need not to see material entering

the syringe.
Stopped aspiration as soon as blood appear in the hub of the
needle.
If the lesion is cystic, the fluid aspirated into the syringe and sent
to cytology laboratory for processing
Sometimes aspiration must be repeated several times.
When aspirating large masses, it should be keep in mind that
the center of tumor maybe necrotic the needle should be
placed in the periphery of the mass
Europian cytopathologist prefer air dried Romanowsky stain.
American favors alcohol fixed smear Papanicolaou or HE

ADVANTAGES OF CYTOPATHOLOGY
Less trauma.
No complication of anesthesia because does not

need general or local anesthesia.

A large sampling surface is available.
Tumor that are difficult to access by biopsy may be
sampled by cytological methods
A rapid diagnosis
Greater convenience
Combining with biopsy Increased detection rate of
malignancy
A greater cost effectiveness

APLICATION OF CYTOPATHOLOGY

Screning for the early detection of

asymptomatic cancer.
Diagnosis of Symptomatic Cancer.
Surveillance of Patients Treated for cancer

SCREENING IN THE EARLY DETECTION

OF ASYMPHTOMATIC CANCER
The most important application of cytopathology cancer

prevention is Paps Smear.

Paps Smear Reduction of Cervical Cancer in the USA and
other country.
The rate of decline varies from one country to another
Depending on the proportion of the Population Screened.
Bladder, lung and endometrium cytopathology is useful in the
detection of cancer in the early stages
Economic Consideration preclude mass screening
Specific population in high risk:
Uranium mine workers Lung cancer
Ulcerative colitis Ca Colon
In China Oesophageal cancer Cytological screening.

ADVANTAGES OF CYTOPATHOLOGY
1. LESS TRAUMA

Fewer complicationhemorrhage or
perforation.
FNA of Pleura open biopsy or large
needle biopsy.
Brushing the surface of endobronchial tumor or
colonic lesion biopsy.
Hemorhage,infection or tumor spread
is negligible.
Complication of anesthesia are no concern
because usually does require general or local
anesthesia.

ADVANTAGES OF CYTOPATHOLOGY
2. A Larger sampling surface is available
Endoscopic procedures
Peritoneal Washings
3. Tumor that are difficult to acces by biopsy may be
sampled by cytological methods.
4. A rapid diagnosis
5. Greater Convinience
6. An increased detection rate of malignancy in
endoscopic procedure is achieved by
combining cytological sampling with biopsy.
7. A greater cost effectiviness

LIMITATION OF CYTOPATHOLOGY
Clasification of the typhe of tumor is more difficult.
The pattern of tumor infiltration and invasion to vasculer can

not be evaluated.
The small size of the specimen may preclude accurate
clasification of some neoplasm with mixed elements
adenosquameus carcinoma, carcinosarcoma.
The extent and depth invasion cannot be assessed In situ
carcinoma and invasive carcinoma.
microinvasive deeply invasive cervical Paps Smear.
Intraductal carcinoma Invasive Ductal Carcinoma of the
breast in FNA.
in situ carcinoma invasive transitional carcinoma in
cytological examination of urine.

ACCURACY OF CYTOLOGICAL
METHODS.
The accuracy cytological diagnosis depends on:

The experience of the collector of the specimen.

The target organ
The expertise of the examiner
False positif are rarely made by experienced
cytopathology Specificity 100%.
Sensitivity 80-90 % depends on specimen
Cerebrospinal fluid 30% of primary and 50%
of metastastatic cancer.
Low grade transtitional carcinoma little or no atypia
difficult to detect High grade neoplasms diagnosed
corectly
The existence of false negative result the abcense of
malignancy does not completely rule out.

CAUSES OF ERROR IN CYTOLOGY

INADEQUATE SAMPLING
POOR FIXATION OF THE SMEARS OR

INADEQUATE PRESERVATION OF FLUID.

SUBOPTIMAL LABORATORY
PREPARATION AND STAINING.

POOR FIXATION OF THE SMEAR OR

INADEQUATE PRESERVATION OF A FLUID
Pap Smear ethanol 95% or spray fixative

immediately. A few scond of delay can cause air

drying artefact difficulty in interpretation.
Cell in body fluid undergo degeneration.
Rate of degeneration Depends on the body fluid.
Pleural effusion long.Urine and cerebrospinal fluid
Rapid.
To prevent:
Fluid must be transported and processed rapidly.
A preservative should be used.
Ethanol 50% an equal volume is good.
Refrigeration slow degeneration and bacterial
growth.

SUBOPTIMAL LABORATORY
PREPARATION AND STAINING
Diffulty in the interpretation.

Examples:

Inadequate cell concentration

Poor adhesion to glass slide
Thicks smear
Overstaining

INADEQUATE SAMPLING
Paps Smear should contain endocervical

cells
Sputum should contain pulmonary
macrophage.
Peritoneal washing should contain
mesothelial cells
Smear of cutaneous vesicle squameus cell
Gastric brushing epithelial cell

MORPHOLOGICAL PARAMETERS USED

IN CYTOLOGICAL EVALUATION
CELLULARITY OF THE SPECIMEN

CELL ARRANGEMENT
CELL SIZE AND SHAPE
CYTOPLASM
NUCLEUS
MITOSIS
EXTRACELLULAR MATERIAL AND

CELLULAR BAKGROUND

CELLULARITY OF THE SPECIMEN (1)

Factor influence the cellularity:

Sampling method brushing or washing

Device Spatula or cytobrush
Expertise of the the physician
Typhe of tissue being sampled
Epithelial cell easier than stromal cell
Malignant cells lower cohesiveness than benign
cells amount of conective tissue Low CT
easier than more CT Lymphoma
Scirrhous carcinoma

CELLULARITY OF THE SPECIMEN (2)

In general abrasive method produce more cells than

spontaneously exfoliated. Brushing sputum

In FNA
Larger size needle produce more cells than very
thin one.The expertise of the aspirator:
The placement of needle
Technique of aspiration
Dilution of cells with excessive blood
In general carcinoma have higher tendency to
exfloaliate cell than sarcoma

CELL ARRANGEMENT(1)
The tissue pattern is lost
The relation between cells is a helpful

criterion for cytological diagnosis

Cells may appear:
Singly
Small groups
In monolayer sheet
Three dimensional cluster
Several cells fuse forming large
multinuceleated cells syncytium

CELL ARRANGEMENT(2)
Cells cluster may form:

Papillary configuration: papillary

transitional cell carcinoma, papillary
adenocarcinoma, malignant
mesothelioma.
Glandular or tubular structure:
Adenocarcinoma
Follicles : Follicular adenoma
Rosettes: Neuroblastoma
Pearls :Squameus cell Carcinoma

CELLS SIZE AND SHAPE(1)

The size of tumor cells varies greatly depending on

the typhe of neoplasm

Small regular cells:
Small carcinoma of lungs
Some typhe of lymphoma
Many typhe of childhood tumor
Large cells:
Squameus cell carcinoma
Giant cell carcinoma
Pleiomorphic sarcoma
Choriocarcinoma

CELLS SIZE AND SHAPE(2)

Malignant neoplasmas greater variability in cell

size anisocytosis
! Well differentiated adenocarcinoma + low grade
transitional carcinoma --. Little anisocytosis
Marked anyisocytosis lymph node
hyperplasia + radiation effect.
Malignant tumor exhibit marked variation in cell cells
shape (Pleiomorphic)
Benign neoplasms are generally monomorphic..

CYTOPLASM(1)
Evaluated in :

color,texture,presence of inclusions,
vacuoles, pigments and other cell
product.
Papanicolaou Methods pink to blue
keratin orange color.
Pigments : melanin,hemosiderin,bile,
lipofuscin, carbon particles helpful in
identifying cell typhe.

CYTOPLASM(2)
Single or multiple vacuoles degenerative

changes, secretory activity or phagocytosis

Viral and chlamydial infection inclusion in
cytoplasm
Squameus cells infected by HPV Koilocytic
atyphia
Reactive or neoplasma of plasma cells
eosinophylic globule Russel body

NUCLEUS(1)
Important parameter:

Size and shape of the nucleus

Alterations of nuclear membrane and
chromatin.
Prominent of nucleolus
Nuclei of normal cells little variation in size
and shape.
Modest enlargement normal cell during S
phase, reactive or regenerating cells

NUCLEUS(2)
Malignant cells significant nuclear enlargement

increased nuclear to cytoplasmic ratio.

Significant variations in nuclear size and shape
anisokaryosis.
Irregular contour with protrusions, identitations and grooves
Molding of the nuclei against one another seen some
tumors
clasically in small cell carcinoma
The nuclei of cancer cells are usually darker hyperchromatic,
Chromatin coarser and unevenly distributed

MITOSIS
Mitotic activity can occur in both benign and

malignant cells.
Cancer cells in general have a higher rate of
mitosis.
The presence of abnormal mitosis:
abnormal distribution of chromosones
more than two mitotic poles
reliable criterion for the diagnosis of
malignancy

EXTRACELLULAR MATERIAL AND

CELLULAR BACKGROUND(1)
The back ground of the smear is evaluated

for the presence of :

Inflammation
Blood
Various extracellular substances
Cell products
necrotic debries
microorganisms
Type of inflamation
(acute,chronic,granulomatous ) and some
varities of microba can be identified

EXTRACELLULAR MATERIAL AND

CELLULAR BACKGROUND(2)
Cell necrosis may occur in benign conditions

infection, trauma, ischemia and irradiation.

In the absence of recognizible intact cells a
definitive diagnosis cannot be made
When presence with malignant cells necrosis is
generally an indication of invasive cancer.
Carcinoma in situ of cervix no necrosis invasive
carcinoma necrosis
The criterion of necrosis cannot be generalized.
Carcinoma in situ of the breast may contain foci of
necrosis Comedocarcinoma.

SMEAR BACKGROUND IN
CYTOLOGICAL SPECIMENS
Inflammation (acute,chronic,granulomatous).
Microorganisms:

Bacteria
Fungi
Helminth
Protozoa
Necrotic debris
Blood.hemosiderin
Mucin
Amyloid
Colloid
Psammoma bodies
Curschmanns spiral
Charcot Leyden Crystals
Renal casts
Urinary crystals

REPORTING SYSTEMS
VARIOUS METHODS HAVE BEEN USED.

PAPANICOLAOU:

Class I : Absence of abnormal cells

Class V: Conclusive Evidence of Cancer

1988: A group of Pathologist and
Gynaecologist met in Bethesda, Maryland
USA The Bethesda System
1991: Revised the original classification

THE BETHESDA SYSTEM(1)

Each cytology report should include the

following elements:
A statement regarding the adequacy of
the specimen.
A general categorization of of the
diagnosis ( as within normal limits,
benign cellular changes or epithelial
cell abnormality
A descriptive diagnosis

THE BETHESDA SYSTEM(2)

The elements must be presents to deem a cervical smear

satisfactory for evaluation:

1.Technical intrepretability (optimal smearing, proper
fixation, lack of exessive blood or inflamation)
2.Adequate samping of the transformation zone
(presence of ectocervical cells and endocervical cells)
The Bethesda System Introduced a new clasification for cervical
precancerous lesion:
1.Low Grade squamous intraepithelial lesion (HPV
infection and mild dysplasia).
2.High Grade squameous intraepithelial lesion ( Moderate
dysplasia, severe dysplasia, carcinoma in situ).